Care for the Patient with Oesophageal Perforation
Oesophageal perforation was discussed in Question 3 from the first paper of 2011. and Question 16 from the second paper of 2016. Specifically, Boerhaave's syndrome is the oesophageal perforation which one sustaines in the course of vomiting. The classical case, I suppose, is that of gross gluttony followed by forced vomiting, as was the case which claimed the life of Baron von Wassenaer, Grand Admiral of the Dutch Fleet. All other forms of non-vomit-induced oesophageal perforation appear to be non-eponymous.
Clinical features of oesophageal perforation
In one retrospective audit, the following features were commonly noted:
- Subcutaneous emphysema in 69.4%
- Pain in 66.7%
- Dyspnea in 38.9%
- Fever in 33.3%
That's right, subcutaneous emphysema was one of the presenting complaints in over 1/3rd of patients. The pain is usualy retrosternal or pleuritic.
- CXR looking for pneumomediastinum
- Occasionally, a pleural effusion (composed of undigested food and stomach juice) may be present.
- Apparently, about 15% of patients have a confusingly normal CXR.
- CT chest with contrast
- This will demonstrate subtle pneumomediastinum, and may show discontinuities in the wall of the oesophagus, but can be confounded by the motion artifact from cardiac pulsation.
- Gastrograffin swallow (not barium) - this is the "contrast oesophagogram" described in the LITFL summary - the gold standard for imaging the perforated oesophagus
- Intercostal catheter to drain pleural effusion and analyse it, looking for acidity (suggestive of gastric contents) and food particles.
- How acidic should it be? Well. Gastric content can have a pH as low as 1.5. The pleural fluid, no matter how infected, should never have a pH lower than 7.0. The presence of gastric contents should lower it below 6.0.
- Also, a gastric content-based pleural effusion should have an elevated amylase level.
Back in my day, the only options were surgical. Any sort of conservative management has come on the menu only since TPN became available.
Thus, the options of definitive treatment are surgical, endoscopic and conservative.
- Primary repair: patch-over for the perforation.
- Exclusion and oesophageal diversion (i.e. the oesophagus opens into a pouch attached to your neck, and a re-anastomosis is carried out once the sepsis settles down).
- Resection and reconstruction which is delayed, as it is essentially an Ivor Lewis procedure and therefore would be disastrous in the setting of a big stinky empyema.
- Drainage +/- decortication of the pleural effusion is usually something that can wait, and only needs to be urgent in those patients whose ventilation is severely affected (i.e. if you cannot extubate them safely with an undrained effusion ).
- Endoluminal stenting can be used in situations where there is no overwhelming mediastinal sepsis. Small or incomplete perforations are best managed eitehr conservatively or with endoscopic stenting.
- This option is particularly good in situations where the perforation is actually due to a malignancy rather than just vomiting.
- Complications might include stent migration, and worsening perforation (i.e. the endoscope can actually complete an incomplete perforation).
- TPN: they won't be eating for a while
- Broad-spectrum antibiotics - it is controversial as to whether or not the patient should be offered antifungal drugs, because the upper GI tract is usually colonised with some Candida species. Biancari et al (2013)
- Proton pump inhibitors to encourage the process of oesophageal repair
- Eventually, these people end up having surgery - but it is delayed until the empyema or mediastinal abscess are well-circumscribed.
- The outcome is surprisingly good in selected patient groups- Hasan et al (2005) saw a survival rate of 84% in patients with an average age of 59; of the dead, all died of something other than mediastinitis.
Idiosyncratic issues of ICU management
There are a few little details about the perforated oesophagus which must be considered:
- No positive pressure without intubation: even high flow nasal prongs can blow gas into the mediastinum.
- Thus, no bag-mask ventilation with intubation. All of these patients should be getting an RSI-like induction.
- TPN should probably start early because it is unlikely the patient will be fed within 7 days of their perforation.
Outcomes in the elderly
Presumably to reduce the incidence of horrendoplasty, Biancari et al published on the "Treatment of esophageal perforation in octogenarians" in 2014. Surprisingly, this small scale (33 patient) observational study did not reveal much of a mortality difference between surgical, conservative and endoscopic approaches. The mortality at 30 days was approximately 40%. These were not randomised patients, suggesting that those (11 of them) who were operated on were probably reasonably fit in order to be even considered.